Three resources to prevent medical errors during transfer of care


Medical errors can be costly for both patient and hospital. As defined by the Joint Commission: In order to keep patients safe, clinicians should focus on the three key points along the patient’s continuum of care. To help, we offer these free resources:

1. Upon admission
Patient admission is a critical time for risk assessment. Clinicians should employ screening tools to identify high-risk patients before procedures. For patients potentially receiving opioids, this can include the Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose (RIOSORD).

2. Patient recovery
As patients recover from procedures, it is common for patient controlled analgesia (PCA) pumps to be employed to manage pain. The Physician-Patient Alliance for Health & Safety (PPAHS) PCA Safety Checklist is a free downloadable resource developed by a panel of experts to reduce the risk of opioid-related adverse events.

3. Patient discharge
Clinicians should take steps to actively engage patients and their families as partners in their health. Patients are encouraged to ask the following five questions about their medications: 

1. Have any medications been added, stopped, or changed, and why?

2. What medications do I need to keep taking, and why?

3. How do I take my medication, and for how long?

4. How will I know if my medication is working, and what side effects do I watch for?

5. Do I need any tests and when do I book my next visit?

We encourage clinicians to download a PDF version of these five questions and share it with their patients.

For more resources dedicated to patient safety, please visit the Canadian Patient Safety Institute (CPSI) and PPAHS websites.

—Stephen Routledge, MPH
Patient Safety Improvement Lead
Canadian Patient Safety Institute 

—Michael Wong, JD
Founder and Executive Director 
Physician-Patient Alliance for Health and Safety


This posting has not been peer reviewed by the BCMJ Editorial Board.


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